A Country Doctor Writes:

“Joel, let’s not kid ourselves. Whatever we diagnose, most patients, if they don’t die, get well by themselves. Our job is mainly to try to make them feel better. Do no harm.”

Leonard Quinhagak, the Healer (Northern Exposure)

I never enjoyed covering for Dr. Ferguson. She was a nice woman and her patients adored her. She advised them on not only their medical conditions and their treatment, but also recommended vitamins, supplements, herbals and macronutrients. A patient who came to see her for a simple cold usually left with half a dozen prescriptions or recommendations for over-the-counter remedies.

When she was out of the office and I happened to see any of her patients for some type of respiratory infection, I always had the feeling they were disappointed and confused. They seemed to expect more than my minimalist treatment suggestions for their self-limited problems.

In my view, no treatment is entirely harmless. Decongestants can stimulate the heart. Antihistamines suppress young children’s breathing. They can also thicken mucous and cause sinus infections, and in older men they can cause urinary retention. Cough suppressants can cause psychiatric side effects. And antibiotics can cause everything from yeast infections to allergies to superinfections.

The allopathic physician community has gradually started to turn away from prescribing unnecessary antibiotics for respiratory infections, but many of us are instead recommending Echinacea and other non-prescription remedies, often without experience or formal training and without basing their use on the same kind of evidence we base our allopathic treatments on.

My brother-in-law and sister-in law are both chiropractors. We don’t talk shop a whole lot, but I remember vividly how they handled their little boy when he was miserable with cold symptoms. They would wipe his red and congested little nose and tell him he was going through a cleansing. They made it sound like something good, almost as if it would leave him a healthier person after he was through with it.

How refreshing, providing a context, framing the experience, rather than suppressing it with substances that could easily backfire.

In Northern Exposure, the TV drama series from the early 1990’s, a young New York physician ends up in a Public Health Service position in a small community in Alaska. He clashes with the Native American healers now and then when he claims to have a monopoly on treating his patients. Many of them freely seek the advice of both the medicine man and Dr. Fleischman.

When a young female patient develops a scaly, itchy rash over most of her body, Dr. Fleischman diagnoses an allergy and prescribes steroids.

Leonard says to Dr. Fleischman:

“It’s wonderful how quickly you can make a diagnosis.

I, on the other hand, spend hours with patients. Sometimes days.

I go fishing with them. I eat with them.

I spend the night in their homes.

It’s not just time consuming.

It’s taxing.”

Shelly continues to be miserable. Leonard, the Healer, spends time listening to her stories and memories and helps her see her rash as a renewal process, a shedding of her old skin, and not something frightening. Her condition resolves and her skin becomes smooth and healthy again.

In the TV episode, Leonard had asked to observe Joel at work, but it is the young physician who has the most to learn from the older Healer’s visit to his office.

The last time I rented a car at the Stockholm airport, I felt a little nervous filling up the gas tank. The brand new Volvo was a flex-fuel car and the Swedish gas pumps had more choices than I was used to. After fretting about it for a few moments, I still chose the familiar unleaded gasoline over the E85 ethanol, which I had heard of but not run into in my rural home state in America.

Our bodies are even more adaptable than modern car engines. Yet, there is a lot of controversy about which fuel is best in certain situations. Not long ago there was a new official edict, replacing the latest version of the food pyramid with an image of a properly stacked dinner plate.

Last week, my mother in Sweden asked me if I had heard that you could lose weight by eating bacon and eggs for breakfast. I reminded her that when I was a vegetarian, between the ages of twenty and thirty-five, my weight climbed steadily as I filled up on oatmeal (I should write more about the oatmeal fallacy some day), cheese sandwiches, rice and pasta. She remembered that my weight dropped when I reintroduced some more protein in my diet.

My mother was recently diagnosed with Type 2 diabetes. She, like many of my patients over here, hears from her diabetes nurse that she needs to take in a steady dose of carbohydrates, because “her body needs them as fuel”.

It seems that many Swedish and American dietitians share the same idealistic view of what diabetics should eat.

The trouble is that some people’s bodies aren’t flex-fuel bodies anymore. Their Type 2 diabetes makes their carbohydrate burning terribly inefficient, so they actually run better on protein and fat. The dietitian community gets the heebie-jeebies about this, because they prefer to prescribe a “balanced diet”.

If the manual of that rented Volvo said to fill it up with gasoline every other time and E85 every other, and the car sputtered and stalled every time I filled it up with gasoline, I would ignore the manual and drive it on E85 all the time.

I tell my diabetic patients that I agree with the notion that a balanced diet is generally best, but that their diet so far has probably been unbalanced enough to stress their carbohydrate burning system. It is as if they have already had their lifetime supply of carbohydrates and they now need to correct that imbalance.

If a diet that works well for non-diabetics sends Type 2 diabetics’ blood sugar through the roof, it can’t be the right diet for them. This is where my patients get to practice their own evidence-based medicine; I ask them to check their blood sugar two hours after their most common foods and to start modifying their meal choices according to their blood sugar results. Then we check their weight, long-term blood sugar and cholesterol profiles. When every single parameter looks better, we know that together we have taken a step in the right direction.

In reality, even Type 2 diabetics have some remaining flex-fuel capability. The challenge is not to use up this ability, but to maintain it as long as possible by limiting carbohydrate intake enough to keep blood sugars reasonably low without relying on drugs, which never work as well as the right kind of diet.

Food pyramids and popular diets come and go, and the theories behind them may seem confusing. But every patient with Type 2 diabetes has the tools (their lancet, glucometer, pencil and paper) to see what type of diet actually works when the “usual” way of eating just continues to make things worse.

There were two “suits” and several boxes of free pizza in the lunchroom when I stopped in to grab some coffee the other day. The enthusiastic young drug “rep” spoke rapidly while our staff ate. His regional manager watched and listened.

Drug “reps” are the only people you ever see in a doctor’s office around here wearing suits. The younger man’s three-button narrow-lapel suit was black and a little shiny, his permanent press point collar shirt a classic French blue, but his striped tie definitely too large for his narrow collar. His senior colleague wore a pinstriped double-breasted dark gray suit with a white spread collar shirt, a perfectly tied half Windsor knot and tasseled loafers.

The two men seemed very out of place in our rural clinic, and so did the medication they were promoting.

The new drug, first in its class, won’t make patients feel any better, live any longer or breathe significantly better. Statistically, it will help reduce the number of exacerbations of chronic obstructive lung disease in patients already on maximum medical therapy.

Most insurance companies don’t even cover the drug, but the fast-talking young “rep” rattled off several things we might want to write down on Prior Authorization requests in order to get it approved. He suggested we refer to the GOLD treatment guidelines, which mention the new drug class without specifically recommending it.

“Side effects? Some people – excuse me for mentioning this while you are eating – experience diarrhea, and some get psychiatric symptoms, which would be a reason to stop the drug.”

At that point I almost choked. Not that I am the least bit squeamish about the mention of bodily functions while I eat or drink, but because of the overly casual mention of the risk of psychiatric side effects.

If a medicine for chronic bronchitis with an unknown mechanism of action can make patients suicidal, it seems to me that a small group of country doctors in remote, rural America should not be among the first ones to prescribe it. It sounded to me as if we must have been the second choice for a drug launch because the pulmonologists downstate wouldn’t pay enough attention to the “suits” representing it.

I excused myself and went back to my office.

I racked my brain. Medical school was a very long time ago. Phosphodiesterase? Cyclic AMP? Viagra, what else? My computer had some more answers.

Phosphodiesterases (PDE’s) were first isolated in rat brains forty years ago.

Xanthines like caffeine and theophylline (an almost outdated COPD drug with a lot of toxic side effects) are non-selective phosphodiesterase inhibitors.

Sildenafil (Viagra) is a PDE-5 inhibitor, and it has found some use in severe pulmonary disease (Revatio).

The new drug is the first PDE-4 inhibitor in clinical use. Earlier compounds in the same class were shown to have severe psychiatric effects and never turned into useful medications.

PDE-4 inhibition stimulates pyramidal cells in the brain, but it is not exactly known what the clinical effect of that might be. People have looked for psychiatric uses for this type of chemical, but the results of that research are still inconclusive.

I also found a less than flattering review on an internal medicine website that summed it all up nicely for me.

So there I was, having listened to a sales pitch for a drug that essentially does very little for only the sickest of COPD patients but might be opening Pandora’s box as far as brain chemistry goes. Not my cup of tea.

I turned to the pile of mail on my desk. On top was a faxed sample offer for a new drug to treat travelers’ diarrhea. I turned to my computer again: Average retail price $300. I stopped right there and tossed the piece of paper in my wastebasket.

By that time it was one o’clock and my first patient of the afternoon, a 75-year-old man with severe COPD, was ready to be seen.

“So when did you get hooked on opiates?” I asked matter-of-factly.

The young man’s low-hanging black jeans were frayed at the bottom. He wore a black hooded sweatshirt – lightweight, but still out of place in the hot weather. His earlobes were pierced and stretched out with black hollow cylinders big enough for me to look through and out the window behind him.

I had seen dozens of his kind before, in my son’s junior high school class, at the skateboarding rink and around town. I figured I knew what kind of music he used to listen to and how he had acted toward his parents and teachers. I wondered if he had dropped out of school.

His clothing style seemed a little young for being at the opiate replacement clinic, where most of the patients were in their mid-twenties or older and weren’t rebelling against anything anymore. Had he arrested in teenage rage somehow?

“I started in high school”, he began. “I was angry at everything and everybody. I grew up having all kinds of skin infections, and then I was diagnosed with Chronic Granulomatous Disease. I had all these painful abscesses, and the doctors gave me hydrocodone. But it was in college I became addicted. I started my own software company and made lots of money. We partied a lot.”

He was bright, articulate, ambitious and successful, except when it came to conquering his drug habit. I realized I had typecast him because of his appearance.

At the end of our visit he paused on his way to the door.

“May I ask where you are from?” he said.

“Sweden”, I answered.

“Oh. You look exactly like my great-uncle Dieter from Germany. You’re an absolute Doppelgänger, but you are a lot nicer to deal with!”

“Definitely not your average kid”, I thought to myself as he described his great-uncle, a stern and meticulous clergyman, who sounded like a character in an Ingmar Bergman movie.

The young man had misjudged me just as much as I had misjudged him when we first met.

It got me thinking about how we instinctively and automatically form opinions of others based on general appearance or similarities with people we know. We need to be aware of this tendency that we all have and careful not to let it go too far, but I don’t think it is altogether useless or undesirable.

The “types” we recognize when we “typecast” each other often represent ancient and fundamental life-roles, or archetypes. Just like the characters in classic fairy tales remind us of people we know and tell us something about ourselves and our own time, we can sometimes understand our fellow human beings better if we look for similarities between them and the archetypes we all carry in our collective consciousness.

Jungian psychology uses archetypes to make sense of human behavior and emotions. Archetypal medicine goes further, by viewing symptoms as physical manifestations of emotions and the archetypes they represent. In archetypal medicine there is no difference between symptoms of the mind and symptoms of the body. A gut-wrenching experience and an intestinal blockage are one and the same process, the ultimate form of psychosomatic medicine.

Jung challenges us as physicians to see the epic drama behind the everyday internal and external conflicts our patients grapple with. The young man dressed in black in his revolt against a family of white-clad clergymen could be a character from Shakespeare or an even older literary master. Jung’s picture of health is a balance between conflicting subconscious forces, as when the young man can finally wear both black and white, and even gray.

Archetypal medicine would ask what the painful boils represent in the tragedy of the talented young man with his opiate addiction. “Illness as Metaphor” has long been the purview of alternative health practitioners. We allopaths aren’t usually willing to go that far, but I have read some thought-provoking treatises about common diseases like asthma viewed in such a way.

Archetypes, in everyday medicine, can offer glimpses into possible causes for behaviors and emotions. In a fifteen-minute visit for anxiety, headache, heartburn or opiate addiction they sometimes offer a deeper understanding than the typical questions we now ask. Does it really matter if a patient has generalized anxiety or panic disorder? Migraine or tension headache? Hiatal hernia or poor dietary habits? Or would we be better served by getting a thumbnail sketch of what the basic issues are that drive a fellow human being toward poor health or dis-ease?

“Burnout skills are the actions at which you excel, that people identify as your strong points but which drain you of motivation. They are unable to energise you and therefore deplete you without refueling you.”

                                                                                                                                                     Claire Burge

Physicians solve problems. We always look for ways to make bad situations better. We rarely say that we can’t help a patient at least in some fashion, even if we can’t cure them. More often than not, we treat patients within the confines of financial or administrative limitations we have no control over.

Physician burnout is a common topic these days. Doctors blame patients, insurance companies, healthcare administrators and the government for their job dissatisfaction.

When thinking about what might put me at risk, I have always thought of burnout as a consequence of external forces or immovable obstacles.

The other night I suddenly realized I have always had the wrong perspective on how burnout occurs. It doesn’t happen to us, we bring it on ourselves.

My wife and I have taken to reading daily reflections after dinner. One of our choices the other night was provocatively titled “Not Every Skill Is Profitable”. The subtitle was even more provocative: “In fact, some will just burn you out.” The writer referred to a South African blogger and businesswoman, Claire Burge, whose words in one instant changed my understanding of burnout:

“Burnout skills are the actions at which you excel, that people identify as your strong points but which drain you of motivation. They are unable to energise you and therefore deplete you without refueling you.”

Claire Burge was experiencing burnout and met with a career psychologist, Aine Mahony, who encouraged her to look at the difference between those skills that can drain you and those that can motivate and energize you. Burge writes:

“My entire career to date has been made up of my burnout skills and I have continually pursued these areas with intensity because everyone has always told me to work within my strengths. Aine states that this is why I am where I am.”

I realize now that my strength as a tenacious problem-solver can be a burnout skill if I choose to take on problems that are ultimately unsolvable or go beyond my scope or authority as an employed primary care physician. When I can’t fix such problems, I feel frustrated and drained. My strengths as a diagnostician, communicator and motivator are my energizing skills. I need to use and cultivate them more in order not to risk burnout in my career.

Three months after her first meeting with Mahony, Burge felt alive and energized by her career and the new direction she was taking it. Her blog post ends:

“Tonight over barbecued hamburgers and grilled mushrooms I tell Calvin about my day. My last words end something like this: It didn’t really feel like work today. I was having so much fun.”

How many physicians today say that over dinner with their spouse?