A Country Doctor Writes:

It was spring. My medical school class, two years along in our five-and-a-half year endeavor, had earned the “medicinae kandidat” degree. We were now worthy of leaving the basic sciences and research center on the outskirts of town and starting our preparatory clinical, “propedeutic” semester at the University Hospital. In Sweden, at that time, we used a lot of Latin words and phrases. Crohn’s disease was  Morbus Crohn, chart notes listed physical exam findings by Latin names for the bodily organs: Cor for the heart, Pulm(ones) for the lungs, Hepar for the liver, etc.

Uppsala Academic Hospital was an imposing campus, with several tall, white towers, housing the most modern wards, laboratories and operating theaters. We were relegated to a pink stucco building that housed the old tuberculosis clinic.

The physical exam course was taught by a couple of older pulmonologists. At first they struck many of us as relics from a bygone era, but as the course went on, our respect grew. These unassuming physicians could percuss a patient’s chest wall and describe in detail what the x-ray would look like, they made us feel the tip of the spleen by turning the patient on his right side, they measured jugular venous pulsations and pedal pulses.

Sometimes we had real patients with remarkably abnormal findings to examine, but we often were charged with examining each other for assessment of normal physical exam findings.

My partner for the Lymphatic System module was Sven Björk, a slow-talking kid from the very north of Sweden. He had jet black, completely straight hair and a broad face with eyes set wide apart. He was part Same, the native, reindeer-herding nomadic population from north of the Arctic Circle.

Sven was a bright young man. He had memorized the anatomy quicker than I had, well ahead of the exercise. Yet he seemed nervous. I soon found out why: he had noticed several enlarged submandibular and anterior cervical glands on himself. We compared each other’s necks and jaw lines, but found to our surprise that our lymph nodes were about the same size.

My glands had been big as long as I could remember; I had gone through repeated strep infections. In second grade I missed 42 days in just one semester. Sven had never had strep throat, and he didn’t remember feeling any enlarged lymph nodes before, but he had never checked himself quite like this before.

Our instructor came over to see how we were doing. Sven cleared his throat and started telling Doctor Bruun what both Sven and I had noticed on his neck.

The fifty-something doctor put his hands on Sven’s neck. Methodically, he worked his way up, down and around the neck and down into the armpits. He had Sven lie down on the exam table, supine for the liver, on his right side for the spleen, then reached for the lymph nodes in Sven’s groin. His face was serious as he whisked Sven off to his office, leaving me standing, feeling my own cervical lymph nodes, bigger than Sven’s.

Sven was diagnosed with Hodgkin’s Disease, a type of lymphoma that wasn’t quite as easily cured then as it is now, but Sven responded well to the treatment and didn’t miss much school.

The rest of our class, me included, went through a prolonged case of what our instructors called Morbus Propedeuticus, Medical Student’s Disease. It is natural to worry that you might have some of the bad diseases you learn about in medical school. Seeing one of your classmates develop cancer sets the stage for more than the normal amount of hypochondriasis.

I realized that even though Sven’s and my lymph nodes were similar, his had developed quickly without reasonable explanation and mine had been there for years and had their origin in my recurrent episodes of tonsillitis. I did ask my instructor to check me over, which he gracefully did. He was not worried, and I accepted his assessment. I never again worried about having a dreadful disease, but I often thought of Sven and me during that physical exam class; there but for the grace of God go I.

Around the time of my birthday a couple of weeks ago, I suddenly thought of Sven again: I know he was declared cured from his Hodgkin’s, but what about freak recurrences, late cancer treatment effects or other tricks of the Grim Reaper?

Google gave me the answer: Sven is head internal medicine physician at a medium sized hospital. He has published several scientific articles, and was interviewed recently about differences in heart attack survival between northern and southern Sweden. I even found a couple of pictures. Wouldn’t you know it, he doesn’t have a gray hair on his head or wrinkle in his face; he looks younger than I do.

Bless you, Sven. I wonder if you know how often my thoughts have gone back to those weeks we spent together way back then.

Marc Lachance is the perfect consultant. Ten years my senior, he had more than mastered his specialty by the time I came to the area. He had also established himself as a mentor to Cityside Hospital’s residents and many young physicians who sent him referrals or called him for curbside consultations.

Marc used to live in a rambling farmhouse not far from where I live. But then his elderly father, widowed and suffering from macular degeneration, needed more help in order to stay in his own home. Marc moved to the opposite side of the city to be closer to his father. Marc’s wife was able to look after her father-in-law while Marc commuted to his office downtown. When his father passed away, Marc and Elaine stayed put, even though Marc’s commute was long.

Marc would follow some patients through the decades, but more often he would do a consultation and perhaps a follow-up. Then he would dictate a letter, right in front of the patient, to the referring physician with a detailed care plan. Marc welcomed follow-up calls from his colleagues and he insisted on getting continued updates on patients he had seen in consultation.

Unlike many specialists, he prided himself in his broad knowledge of medicine. I often ran into patients who had seen Marc for a consultation pertaining to his specialty, but had been diagnosed with cancer, hepatitis C and other conditions by Marc.

Whenever I called Marc for curbside advice, he told me exactly what I needed to know in order to move forward with my case. He never put me down if my call was disorganized and less than well prepared. But his own clarity of reasoning and exquisite mind for detail always made me feel I had been to school or a motivational seminar: “This is how a physician should be”, was the thought that lingered after getting off the phone with Marc.

Marc’s partner, whom I had fewer dealings with, retired a year ago. Many of us primary care physicians quietly wondered what was going to happen now.

Yesterday, a patient I shared with Marc brought in a letter she had just received. It was a printed letter that read:

“Dear Patient,

After more than 35 years, I will be closing my practice on December 30, 2013. For many years I have commuted a great distance to my office. As I am soon turning 70, and hoping to avoid retirement, I have made the decision to relocate my practice to Meadowview Hospital in Cornish, which is closer to my home. I will be an employee of Meadowview Hospital without the concerns of managing the business of a medical practice. By making this move, I am hoping to be able to practice medicine well into my eighties if I continue to enjoy the good health I have been blessed with.

I would be happy to continue seeing any patients who wish to transfer to my new location, but understand if most of you will want to find a specialist closer to where you are. Drs Jonathan Bard, Sheldon Mintz and Ravinder Pran all accept new patients in their Cityside Hospital Clinic.

I appreciate the confidence you have placed in me and wish you the best future health. Your primary care doctor has always received copies of my notes and your complete medical records are available for transfer by contacting my office at the above telephone number….”

I slowly handed the letter back to my patient.

Marc, I thought, you are teaching me something every time: How to be an up and coming young doctor, how to conduct yourself when you are in the prime of your career, and how to stay in the most fascinating job in the world as long as you possibly can. I know you love medicine, possibly even more than I do. I also know that you are at least ten years wiser than I am about being a human being, a son, husband and citizen of the world.

Bonne chance, mon ami, and may you never retire.

In 2009 I wrote a post titled “Quality or Conformity“, where I pointed out that many of the quality measures in primary care have more to do with whether doctors follow guidelines than if they deliver care that helps patients live long and well. There is a tendency to focus quality efforts on measuring what is easy to measure, rather than what matters the most.

That phenomenon is called the Streetlamp Effect, named after the man who was found searching for his car keys not in the dark alley where he lost them, but under the corner streetlight where he could see better.

Last night and tonight I read four articles in The New England Journal of Medicine and JAMA that made me think again about how elusive an ideal quality is in primary care.

The Case Record of the Massachusetts General Hospital for the week of May 23 was a 12-year-old girl with celiac disease, behavioral symptoms and fatigue. Her final diagnosis was Addison’s disease, a deficiency of the body’s natural steroids. The piece mentioned that most sufferers of this condition live with its often-debilitating symptoms for 2-5 years before diagnosis. The girl in this article had been hospitalized several times before the correct diagnosis was made (at MGH, of course!).

The other piece in The New England Journal was about how Fee-For-Service payment was going to go away and be replaced by payment schemes based on relative value units and adherence to clinical guidelines for chronic disease. This piece specifically mentioned that treatment of (acute) illness would have far less value than managing chronic diseases.

I thought of the man who had been to the emergency room twice before I diagnosed him with scabies a few months ago. Doesn’t accurate diagnosis with new presenting symptoms count for anything anymore?

The first article in JAMA was a very broadly written piece about the future of quality measurements under Obamacare. The second article, written by a group of primary care doctors, was titled “A View From the Safety Net”. These doctors described the difficult choices they had to make between doing what mattered most to their underserved minority population or scoring better on quality measures dictated by outside authorities when they didn’t have enough staff or money to do both. The Obamacare article mentioned striving for patient-centered measures, but it remains to be seen how patient-centered we are going to be allowed to practice in the future.

Quality is still in the eye of the beholder. People in Government, insurance and academia prefer easily quantifiable data and still hold on to arbitrary or outdated numeric targets, even when the evidence to support them is controversial or refuted by science. They are often like the man under the streetlight.

Doctors on the frontlines, who live and breathe the complexity of health, disease and patients’ everyday socioeconomic challenges, know that for every clever metric someone can think up to measure quality, there are countless other factors that can render the quality parameters meaningless. What good does it do to prescribe the right medications for someone with chronic illness when the patient can’t afford them or keeps forgetting to take them?

In the same month my original post was published in 2009, for example, the American Diabetes Association revised its blood sugar targets for older diabetics. The evidence has shown that our usual targets were low enough to cause harm to many frail patients, yet doctors in this country are still given poor report cards if they practice with their patients’ safety and the new evidence in mind.

So, what is quality?

Quality is easing suffering and giving hope, not crunching numbers.

Quality is treating each patient in a sensitive, caring and competent manner.

Quality is serving the patient’s best interest with societal good in mind, not serving society with only an eye toward the individual patient.

Quality is having not only systems to promote safety and good practice, but people who care and invest their talents and abilities for the good of the patient.

Quality is diagnosing a rare disease like Addison’s early enough to give an adolescent girl her teenage years before they are gone.

Quality is making the diagnosis of a common disease like scabies in five minutes in a patient who has already cost himself weeks of discomfort and his insurance the dollar value of two emergency room visits and three prescriptions.

Quality is doing what matters to the patient. If we accept, even endorse, patients’ right to decide whether or not to be resuscitated if their hearts should stop, aren’t we then also allowed to listen to our patients and together with them formulate a care plan that they feel comfortable with for their chronic illness without fear of retribution by some Government or insurance reviewer for not following some more or less arbitrary guideline?

Quality is a word that lacks universal meaning. Every dictionary I have looked in has scores of definitions. It is a word people use for their own purposes.

We must be careful about letting others define the standards for our profession. If people with a more financial and less scientific and humanistic viewpoint set all the standards, technicians and computers will replace doctors.

The quality of a church service is, in my opinion, not adequately measured by how freshly painted the murals are, how well matched the choir uniforms are, how well-shaven the minister is or how clear his voice is when he puts his notes aside and speaks from the heart. If the Government were to set quality standards for churches, those things might be major quality indicators.

Fortunately, Church and State are separate in this country; health care and Government are no longer.

Health care, like religion, has a lot of intangibles, and even its substance is the source of many disagreements. I think that just like people go to church for different reasons, they seek health care for enough different reasons that our quality measures need to be very patient-centered, without losing sight of our “substance”, our foundation of science and humanity.

Quality is about addressing both the intangibles and the substance. Most of us know it when we experience it ourselves; the problem is building systems that guarantee it.

I used to be a stickler for time. One of my first blog posts was about how it felt to go to work without my wristwatch.

I also used to be very particular about knowing the purpose of each visit, partly to help me manage my time, and partly to help me feel prepared and in control of the visit.

I often questioned why my colleagues’ patients would sometimes end up in my schedule for issues that seemed to me safe to wait until the patient’s own provider was available.

Over the last five years I have relaxed about these peeves of mine. I have become more accepting of the fact that patients don’t think in terms of how many minutes they have assigned to them as well as the fact that many patients can’t or choose not to tell the front desk staff why they want to see me on a given day.

Thinking about the way I used to be, I was more efficient than my employer expected me to be, but I don’t believe I quite lived up to my full potential as a healer. There were already then systems in place that made sure the housekeeping aspects of health care weren’t missed for very long if I were to digress in the visit – we had our chronic disease registries and recall systems for pap smears, mammograms and immunizations.

Lately, I have come to think more and more about the physician’s duty to ease suffering. So much of modern medicine is about population and disease management, and there are so many pressures on our time and attention that physicians seem to have little left to offer patients who are suffering, physically or emotionally.

But the systems to manage the measurable aspects of medicine are there, backed up by even more computer power, and we physicians may just need to step back from the numbers long enough in every encounter with each fellow human being to allow us to be open and see our patients as individuals. We need to listen actively to hear their unique agendas. We have teams behind us now to help manage the housekeeping details; we have health coaches and case managers and more nurses than we used to. But since only we have the title “Doctor”, we need to have our senses open to those things only we get to hear.

My wife, reflecting on her years delivering primary health care, always says: “I never had just a Diabetes visit. There was always something else.”

The sad truth is that the health of a nation is more dependent on public health, socioeconomics and the prevailing attitude among the majority of the population. The quality of medical care matters very little. For example, a healthy diet together with an active lifestyle is at least as good a weapon against heart disease as all the cholesterol pills and interventional cardiology that money can buy. It doesn’t take a medical degree to change the attitude of a nation, and trying to do it on a case-by-case basis with each patient at $7 a minute is not effective population management – not that I don’t try every single day.

So, what is the role of the physician in today’s health care system? I believe we are the ones who can best help patients make sense of their symptoms and also understand what the health care system can and cannot do for them.

With common human experiences given names that make them seem like diseases, and with our nation’s increasing confusion about even common ailments and preventive measures in spite of the glut of information out there, physicians can bring wisdom and empathy to a system that provides neither. Since we are closer to the mysteries of birth, disease and death than most people, we need to be there for our patients to turn to when the angst of life afflicts them.

I believe the new systems we have all been required to put in place to meet all the public mandates are actually blessings in disguise. If we are wise, we can meet our quality and productivity metrics through the use of the technology at our disposal and at the same time rediscover and cultivate the ancient art of doctoring. Because the phones at my clinic as well as every other doctor’s office keep ringing, not with patients asking to have diabetes follow-ups, but with patients who have a new concern, a new fear, or the courage – just today, or they will lose their momentum – to finally tell someone their deepest fear.

Pausing, as I do every time before knocking on the exam room door, I clear my mind and I am ready:

“Hi, I am D—. What can I do for you today?”