A Country Doctor Writes:

My wife, who worked side by side with me as a nurse practitioner for over ten years, is my proofreader. She actually worked as a proofreader for a small New England weekly newspaper many years before I met her. She is also my best friend and my sounding board.

My first version of the previous post on this blog didn’t meet with her approval. She pointed out that my narrative sounded jaded and encouraged me to come back to it on a day when I was less tired. I gave the post a few days rest before revising it and felt better about the second version.

The other night, as I was describing a difficult day in the office with a schedule that didn’t make my job easy to do, she reflected:

“You treat your patients better than you treat your staff, or your family sometimes, for that matter”.

I looked up from my dinner plate. She wasn’t joking.

“You can be such a healing presence for your patients”, she said, “but you have a tendency to turn that off in dealing with the rest of us. You could be more healing in all your relationships”.

I thought of what she said. She was right, of course. I can be hard on myself and on those around me. I tend to think of us as working only for the patients or some abstract ideal of perfection rather than also with each other.

How many times have I simply told my wife or my children that their symptoms – sprains, migraines or bellyaches – will go away without offering a fraction of the support my regular patients get in the same situations? And how many times have I been less attentive to their worries and heartaches than I should have been?

I realize my loved ones get less care than they deserve, because “I already gave at the office”.

Do I really think I have a right to switch off my healing presence? I don’t mean that I or any other physician should try to work longer hours or take on more patients than we are able to take care of. What my wife made me think about is my whole way of being:

I always wanted to be a doctor. Now that I am one, I am a doctor every moment of my life. I am not a husband or a father or a pet owner just certain days or hours of my life. Neither one of those roles is “just a job”. Neither is being a doctor, particularly in specialties that profess to treat the whole person.

Obviously, I am still working at it. I’s my New Year’s resolution.

Trevor Dubay was in to see me during a very busy afternoon session on December 22^nd. I hadn’t seen him for almost a year. Last time I saw him he had come in with indigestion and acid reflux and the medication I had prescribed for him must have worked. He had called in for refills 3 and 9 months after his office visit.

This time he was in my schedule with a concern about heel pain. “Plantar fasciitis”, I figured before I knocked on the exam room door.

“Hi there. I haven’t seen you in a while. How’s the heartburn?” I asked.

“Doing good, as long as I take my pills, but I can’t go without them very long.”

“Any trouble swallowing, cough, hoarseness or belly pain?”

“No, not at all.”

“Then, in your age bracket, as long as the pills work, we’d just tell you to keep taking them. Then, maybe at 50, we’d send you for a scope test. Now, today you’re here for some heel pain?”

Sure enough, he had the typical heel pain when he first started walking in the morning and he was worse those days at work when he had to do a lot of walking on concrete floors. His physical exam was consistent with the diagnosis, so I started explaining the mechanism behind his condition and the various things we can do for it – anti-inflammatory medication, ice, stretches, heel cups inside his work boots, ultrasound treatments and, the last resort, steroid injections.

I went to pick up my handout for plantar fasciitis and heel spurs and he agreed to a physical therapy referral. I entered the request into the electronic medical record.

“Why do my hands go numb at night?” he asked when I had finished typing.

“Both hands, all fingers?” I asked.

“Uh-um”, he nodded.

“Ever happen during the day?”

“Once in a while.”

“Any neck pain?”

“No.”

“Show me how far you can turn your neck each way.”

His range of motion was normal, as was the strength in his arms and hands. He had normal feeling in all fingers. Tinel’s and Phalen’s signs were negative – no sign of carpal tunnel syndrome – and Adson’s maneuver was negative – no sign of cervical ribs or any other impingement of the circulation to his arms. He did wince slightly as I pulled his right arm back, though.

“My shoulder’s been sore for years”, he explained.

“That wouldn’t explain both hands tingling, though”, I said. “I don’t think you have carpal tunnel syndrome, and it doesn’t look like a clear cut neck problem, although sometimes too thick a pillow can trigger this sort of thing. I think you have what we call acroparesthesias…”

“What do you think of this rash?” he interrupted, and exposed his neck and upper torso.

“That’s called Tinea Versicolor. It’s an infection that changes how the pigment in your skin behaves, We treat it with athlete’s foot creams, but then you have to tan a little to even out the color sometimes.”

“Oh, I can buy one of those creams over the counter, right?”

“Sure, any one of them. Leave it on for a good ten minutes, then wash it off. Do that once a day for a week.”

“Great.”

“So, for your heels, you’ve got the exercises, you can get the heel inserts, buy some naproxen. They’ll call you from physical therapy for an appointment. And – if all else fails – we can give you a shot.”

He winced.

“So, you and Beth have a good Christmas”, I said as I got up from my stool and reached my hand out towards him.

“You too, but what about my shoulder?”

I paused and glanced at the time; 22 minutes into his scheduled 15 minute visit.

“Well, that’s a whole other project. We’ve covered a lot of ground today already, and my next patient is waiting. We could order an x-ray and have you come back for a full evaluation of your shoulder if you’d like.”

“Never mind”, he said.

Mrs. Carignan was in my schedule this morning for her one-month follow-up. Three months ago I had requested a psychiatric consultation for her, but I had not heard back about any appointment date from RPA, Rural Psychiatric Associates. They had lost both their regular doctors a year or two ago, and had been getting by with locum tenens physicians since then. I had referred Mrs. Carignan because I needed help with both diagnosis and treatment in her case. I was hoping the newly hired permanent psychiatrist could help her.

She had been hospitalized twice, once for a “breakdown” in her forties, and again about ten years ago for what sounded like a manic episode. Since then she had been on several mood stabilizers and a few antidepressants. When her old psychiatrist, Dr. Andrews, left the area, she stopped her medications.

Several months ago, she came to see me about her nerves. She was anxious and depressed, and on top of it was exhibiting symptoms of mild dementia.

My usual armamentarium of medications for someone like her proved useless, and I had finally convinced her she needed a psychiatric reevaluation. After the first month of waiting to hear back from RPA’s appointment staff I decided to put in for a Prior Authorization from Wellcare, her Medicare D prescription insurer, for a more expensive agent for refractory and bipolar depression.

My heart sank when I saw her name in my schedule this morning. There had been no word from Rural Psychiatric Associates and there, right in front inside her paper chart, was the fax we sent off to Wellcare more than a month ago. There was no indication of any reply in her chart. I searched our new electronic medical record. She had no clinical notes in it yet, nothing about any response from Wellcare, and there was nothing in the referral module about a psychiatric appointment.

I checked the time – five minutes into her allotted fifteen minute visit. I called Wellcare with some trepidation. This was likely to take time, but I felt I owed Mrs. Carignan this, since the system – actually three different systems – had failed her.

After only a minute or two on hold I told Wellcare’s customer service representative my errand:

“I am a physician. I faxed you a coverage request more than a month ago and have not had any response yet.”

She politely promised to put me in touch with someone who would be able to help me.

Two minutes later, a young man with a heavy accent offered to help me. I had to spell Mrs. Carignan’s name twice, and he double-checked her birthdate and policy number. He put me on hold and I listened to the same music I had already become familiar with.

“I apologize, Doctor, could you give me your patient’s birthdate and policy number again”, the young man said. I obliged, and he excused himself again. I glanced at the clock above my desk. Five minutes left of her visit, I noted with more than a little concern that I might not be able to do much for her today.

“I am sorry, Doctor, we have a client with the same name, different spelling and not quite the same birth date”, the young man announced when he finally came back on the line.

“This is her Social Security number…”, I offered.

“Let me look her up that way, then, Doctor. Would you mind holding for just one minute?”

I looked at the clock again. Two minutes left.

“Thanks for holding, Sir. I am sorry but we have no client with that Social Security number.”

“I see”, I said. “Well, I have already spent her entire appointment speaking with you on the phone. Thank you very much for looking into this. Good-bye.”

I grabbed her paper chart and my laptop and entered Room 1.

“I’m sorry to keep you waiting, Mrs. Carignan. I have just spent the last fifteen minutes talking to Wellcare, your prescription insurance, about that medication I wanted to prescribe for you. They claim they never heard of you.

“But I’ve been with them for years.”

“Let me call your pharmacy”, I said as I pulled out my cell phone.

A minute later Sandy, the new pharmacist at Williams’ Rexall answered my question:

“Wellcare is paying us just fine for her medications, but the policy number we have is different. It’s 596 0059.”

I wrote down the number, wondering when I would ever get the time to call them back.

Opening my laptop, I said:

“So we have no word from the psychiatry office and your insurance company don’t know who you are.”

She looked puzzled.

“Should I go on taking this”, she asked, reaching into her zippered toiletry bag with all her pill bottles. She produced a small bottle with an antidepressant I had not prescribed for her.

The name of the doctor on the bottle was Mary Meyerer, the new chief at Rural Psychiatric Associates. The fill-date of the prescription was almost three weeks ago.

“Oh, you did get an appointment with the psychiatrist!”

“Yes, and I’m going back next week again…”

“Great. I’m glad you finally got an appointment. You see, some specialists, particularly psychiatrists, don’t tell us when they make an appointment for someone we refer to them.”

“That seems silly…”

“Well, yes.” I paused. “At least you got in.” Looking quickly through her chart I added:

“I see it’s been a while since you had your bloodwork done for your cholesterol. Let me put an order in the computer for that…”

The task bar on my laptop informed me that I was 30 minutes behind, with two patients waiting in exam rooms and a third in the waiting room.

I must admit I had felt a little smug about my discovery of Elsa Bruegger’s faulty walker. It really seemed like a very logical explanation to her walking into walls all the time. As it happened, her new walker didn’t quite solve the problem. She continued to be off balance and sometimes did seem a bit unfocused, even downright sedated.

Looking back through her record, I came across a mildly elevated ammonia level a few months ago. I remember speaking with her psychiatrist back then about Elsa and a couple of other patients we share, whose routine ammonia levels were mildly elevated. Elsa had a standing order from the psychiatrist for ammonia levels every three months because of her valproic acid (Depakote) prescription for her mood disorder.

All my research has led me to the conclusion that ammonia levels are of little or no value in predicting whether patients on valproic acid are headed for trouble due to the drug’s unpredictable tendency to cause ammonia to build up within the central nervous system. I have come to understand that ammonia levels are only slightly helpful even in assessing a patient with coma or near coma; the correlation between brain levels and peripheral blood levels of the toxic ammonia relate poorly to each other because of how the blood-brain barrier works to keep the chemistries inside and outside the central nervous system separate. Many experts recommend against routine measurements of ammonia levels for this reason.

Watching Elsa fumble her way down the hall, I decided to order an ammonia level “just in case”. It came back elevated – twice as high as it had been ten weeks ago. Her liver function tests were normal.

I ordered her valproic acid stopped and made sure her psychiatrist got a copy of the lab report and my notes.

This week, Elsa is finally walking straight. She is attending her day program, says “good morning”, makes good eye contact and smiles. She also shows more of a temper, but nothing inappropriate.

Maybe this time I finally got it right.

“Elsa Bruegger has seemed a little unsteady in the morning lately”, the charge nurse told me at my boarding home rounds two weeks ago. “Her morning blood sugars have been a little low. Do you think we should cut back on her insulin?”

“Sounds reasonable”, I answered. Let me look at her chart.” Elsa is on valproic acid as a mood stabilizer and sees her psychiatrist every three months. Her drug level was just about due to be checked, so I ordered a fresh set of labwork and decreased the dose of her long-acting insulin.

We continued our stand-up rounds, going through dozens of reports and issues on the many residents who were not scheduled to be seen that day. I then did two admissions and saw a couple of patients for their scheduled visits.

The next time I went to the boarding home, I checked on the results of Elsa’s blood tests and reviewed her blood sugar log. Everything was well within range.

“How is she doing?” I asked.

“The girls still find her a little off balance now and then, especially in the morning.”

“Tell me again how long this has been going on…”

“Probably a month or a month and a half.”

“Any urinary symptoms? Anything else going on?” I flipped through the chart again. My eyes fell on some insurance paperwork. There, two months ago was a rejection letter for a Prior Authorization request for a brand-name drug Elsa had been taking for urinary frequency.

“Well, she’s incontinent sometimes, but that’s not new, and she has no dysuria. But we did have to switch her to that generic drug for her urine two months ago”, the charge nurse answered.

“Well, if she’s still incontinent, let’s stop the pill, because that could cause her to be dizzy”, I said, “so let me write the order for that.”

Yesterday I stopped in at the boarding home again to speak with the family of one of my patients. While standing at the nurses’ station I happened to see Elsa coming down the hall with her walker.

With every step Elsa took, she and the walker veered more and more to the right until she came to a stop with the right front wheel against the wall. She then lifted the walker toward the middle of the corridor and started walking again. Eight or ten steps later, she was back against the wall. She stopped and lifted the aluminum walker toward the middle of the corridor again and repeated the same procedure.

“Look”, I whispered to the nurse.

We watched as Elsa repeated her zigzag veer and correction half a dozen times until she came to the TV room half way down the hall. After she settled into her chair, I asked to borrow her walker. She seemed bemused.

I picked it up and spun the wheels, which rolled without any apparent resistance. I checked the length of its four legs and the tightness of all its bolts.

“Let me just take it for a spin”, I said. Elsa grinned as I started walking.

The moment I put even the slightest pressure over the front wheels, the walker started turning towards my right. I hit the wall just as fast as Elsa had. She giggled. The nurse sighed with her hands on her hips.

“Let’s get you a new walker!” I said as I returned the defective unit to Elsa. She smiled and nodded.

I didn’t know whether to feel good or bad about my diagnosis. It had taken more than two weeks, but really only took a minute to arrive at once I got on the right course.