Archive for the 'Progress Notes' Category



Absolute Risk

Gladys Peppercorn was in to see me the other day, very concerned about a letter she had received from one of the Cityside gastroenterologists.

In very formal words, the letter said the GI office had tried several times to reach her in order to schedule her next upper endoscopy to monitor her Barrett’s esophagus and would she please call them back to schedule the procedure so they could monitor her for her increased cancer risk.

“You know me, I don’t want any unnecessary procedures”, Gladys said as I read the letter she handed me. She had only gone for the test two years ago because she had experienced heartburn for years, and at that time certain foods had been a little difficult to swallow. Her test really came out okay except for the Barrett’s esophagus. Her biggest problem with swallowing was some age-related stiffness of her esophagus.

Gladys’ age was not apparent when I looked up from reading the letter. Ninety years old in just a couple of weeks, she looked radiant, healthy and on top of the world in her purple silk blouse and khaki slacks.

“I do hear you, and I’m going to do some math with you”, I said as I pulled my chair over next to hers and minimized the EMR on my tablet computer and opened UpToDate, the medical database from Boston many doctors use as a reference.

“Okay, here are the numbers”, I began as we both peered at the small screen.

“Having Barrett’s increases your risk of esophageal cancer 30-fold”, I said, pointing at the website. Her eyebrows rose slightly. I continued:

“That would be like me saying that wearing purple increases your risk of getting hit by lightning 30-fold. Would that stop you from wearing this blouse?”

“No, it’s my favorite color”, she smiled.

“And thirty times nothing is nothing!” I concluded. She agreed.

“Look here”, I pointed. “Studies have shown between 1.2 and 4.3 cancer cases per 1000 person years in people with your condition. Let’s exaggerate and call it 5 cases per 1000 patient years. That means that out of a hundred people like you, in the next ten years only five would get cancer and 95 would not.”

She nodded slowly.

“So you have at least a 95% chance that you will not get esophageal cancer in the next ten years, probably more in the order of 96-98%.” I continued: “And then you have to weigh that risk against the risk of anesthesia or the procedure itself causing you harm in some way.”

“I know I don’t want the procedure!” Gladys smiled and rose from her chair. I quickly got up, too. She stretched her hand out toward me and thanked me.

“I always feel better after talking to you”, she said.

I shook her hand and thought that she probably used to wear white lace gloves on warm days like this when she was young.

Sharing Territory

How are we educated by children, by animals!

                       Martin Buber

In my forties I was the father of three teenagers. I knew enough psychology to perhaps avoid a few common blunders, but nowhere near enough to do a great job raising the three of them. It would be fair to say I learned from them as we went along.

As an only child, I had lived with many expectations to be just the kind of son my mother always wanted to have. I decided early on not to live vicariously through my children. It is a classic, almost archetypal thing for parents to do; wanting for their children all those things they never had themselves. It seems so natural when you love someone to want the best for them and to want to protect them from harm and mistakes in their lives.

One of my first girlfriends’ father was a minister. He introduced me to Martin Buber’s “I and Thou”. I think he was trying to caution me not to be possessive about his daughter. I did learn soon enough on my own that we cannot love and control a person at the same time.

Love requires freedom, even the love of a child. I set out knowing my children were not miniature versions of me, but their own individuals. The fact that all three were adopted made it more obvious that they might not have come into this world with my traits, likes or dislikes, but that should hold just as true for biological children.

A colleague of mine from India once said about her youngest son, “I hope he grows up to be a good person”. It seemed so simple, yet wise: All we as parents can do is give our children the best start we can and hope for the best. An exasperated neighbor once said about her son, “There comes a time when all you can say is I love you, good luck“.

All three of my children have said, in one way or another, that they appreciated my respect for them as individuals. They have also pointed out that they respected me for letting them know when I disagreed with them.

With my children now around 30 years old and my grandchildren still blissfully young, the only experience I have with teenagers these days is as patients in the office. I can certainly draw from my having lived with three teenagers in those situations, but I am drawing more and more from the past few years’ lessons I have learned from P., our white Arabian Princess.

An 800 lb horse who thinks most humans are likely to hurt her or mistreat her is like some of the teenagers that have come into my office. Domination is unlikely to work with a fearful animal of flight with the power to escape or punch your lights out.

Much of what I have done with P., I figured out myself. Emma also pointed me in the direction of horse trainer Carolyn Resnick, whose “Waterhole Rituals” are a foundation for relationship building between horse and human.

P., fresh from the horse rescue, was suspicious of Emma, who had defended her gelding from the kicks and nips P. tried to inflict on him. Perhaps I seemed like the best choice P. had for an ally, knowing nothing about horses, and expecting nothing in particular from her. Perhaps I reminded her of her first owner, the man who named her and raised her from a foal.

Our white Arabian horse gave me a sense of awe. She was so beautiful; I had never seen the facial expressions and body language of a horse up close quite like that before. Her eyes could be glaring when she looked across the pasture at some danger in the nearby woods I couldn’t discern. Whenever she looked at me and I just stood or sat still in the barn or on the other side of the fence from her, her eyes grew soft and kind. If I got up or made a sudden move, they would widen and the whites would show, her neck would stiffen, her tail would rise and every muscle in her body would tighten. Sometimes she would run away from me. If I just sat there quietly, she would come back with a kind, quizzical look, as if to say, “What are you, what are you doing?”

Instinctively, I was doing the first of the Waterhole Rituals, Sharing Territory. By now, four years later, P. and I trust each other, and she will do almost anything for me. She nickers when I approach her and we go for walks around the pasture, side by side, without halter or lead rope. I clean her stall around her and she moves politely when I ask her to.

A horse will naturally move away from an approaching stranger, but is likely to come over and investigate a stranger standing or sitting still inside the horse’s territory. If the stranger walks away, the horse will likely follow.

This is how I have also come to understand working with teenagers. Just like P., they don’t assume your intentions are good and they don’t like it when you tell them what to do, but if you show that you are interested in them and if your interest is genuine, they may want to know you better. But their senses are exquisite – they can smell deceit or trickery miles away and if you come on too strong, they will run like wild mustangs (or white Arabians).

Which brings me back to Martin Buber:

There are two kinds of relationships we can enter into. One is the “I-It” relationship, where we view ourselves as controlling the “other” by taking pleasure from it/him/her or even just by analyzing or classifying it according to our worldview.

The other kind of relationship Buber named “Ich-Du” in German. It has been translated as “I-Thou”, even though “Du” is an informal, intimate word for “you” and not at all as formal as “thou”. This is a relationship where we meet on a level that is free from selfishness, judgment, opinion, even reflection or analysis. It is an intimate encounter between two beings in their most authentic form. This is also the type of encounter man has with God or the Universe when all the trappings of religious ceremony are removed.

An “I-Thou” encounter lacks structure and content. It has no agenda, because any kind of purpose would objectify the “other” and make it an “I-It” encounter. It is simply entering the common space where both of our innermost beings exist.

“Sharing Territory” almost says it better, especially in light of the fact that Martin Buber actually first thought of the I-and-Thou relationship when he as a pre-teen developed a relationship with a horse.

In “Between Man and Man”, he describes a fleeting moment, when he connected with the horse on a level that stirred an awareness in him and briefly brought him into a universal experience where the horse wasn’t just a horse, but a part of a common “Other”, previously unknown to the young Martin Buber:

“When I was eleven years of age, spending the summer on my grandparents’ estate, I used, as often as I could do it unobserved, to steal into the stable and gently stroke the neck of my darling, a broad dapplegray horse. It was not a casual delight but a great, certainly friendly, but also deeply stirring happening. If I am to explain it now, beginning from the still very fresh memory of my hand, I must say that what I experienced in touch with the animal was the Other, the immense otherness of the Other, which, however, did not remain strange like the otherness of the ox and the ram, but rather let me draw near and touch it. When I stroked the mighty mane, sometimes marvelously smooth-combed, at other times just as astonishingly wild, and felt the life beneath my hand, it was as though the element of vitality itself bordered on my skin, something that was not I, was certainly not akin to me, palpably the other, not just another, really the Other itself; and yet it let me approach, confided itself to me, placed itself elementally in the relation of Thou and Thou with me. The horse, even when I had not begun by pouring oats for him into the manger, very gently raised his massive head, ears flicking, then snorted quietly, as a conspirator gives a signal meant to be recognizable only by his fellow-conspirator; and I was approved. But once–I do not know what came over the child, at any rate it was childlike enough–it struck me about the stroking, what fun it gave me, and suddenly I became conscious of my hand. The game went on as before, but something changed, it was no longer the same thing. And the next day, after giving him a rich feed, when I stroked my friend’s head he did not raise his head. A few years later, when I thought back to the incident, I no longer supposed that the animal had noticed my defection. But at the time I considered myself judged.”

“Sharing Territory”, be it with a horse or a human being, is the purest form of encounter there is. I did not specifically set out to “heal” the wounds of my rescue horse any more than I personally believe I have the power to “heal” a troubled patient. But I have often seen that when you enter the space created by stripping away prejudice, projection and preconception, profound healing is possible.

A Country Doctor’s Unlived Life

“Just as colleges introduce our young people to knowledge of the world important for the first half of life, there should be colleges for forty-, fifty-, and sixty-year-olds to prepare them for the challenges of the second half…”

Robert A. Johnson & Jerry Ruhl

During my vacation I went to the eye doctor to have a refraction done for a pair of reading glasses. Reading my iPad at night with my progressive lenses forces me, now that I am pushing sixty, to turn my head uncomfortably upward to read through the bottom of my thick eyeglasses. With a pair of dedicated reading glasses, I will finally be able to read up close in dim light with my eyes looking straight ahead.

One of the books I am reading is by Jungian therapists Robert A. Johnson and Jerry Ruhl, “Living Your Unlived Life: Coping with unrealized dreams and fulfilling your purpose in the second half of life”. Of course, that’s stretching it for me – last third is a more accurate description of my current location on life’s roadmap.

Back when I really was closer to the halfway mark, I read Johnson’s “He: Understanding Masculine Psychology” and “Transformation: Understanding the Three Levels of Masculine Consciousness”. The title of my current read, “Living Your Unlived Life”, really spoke to me when I first came across it a couple of years ago: I could have done so many different things, but I made decision after decision that eliminated those options and put me where I am right now. And sometimes, in moments of doubt, I wonder what my life would have been like if I had made a different choice at one of those virtual forks in the road. I knew from age four that I wanted to be a doctor, and ever since I first visited this country, I knew I wanted to be a country doctor here. I got exactly what I wanted, but I didn’t quite consider all the consequences of making a life for myself so far away from my family and everything I grew up with.

I was a Scout, very good with map and compass, and spent many a night by a warm fire under the stars in the vast Swedish forest, Kolmården. Some of us played guitar, all self-taught, and we shared chords and riffs as the evenings grew cold and the others went to sleep in their lean-tos deep inside their mummy sleeping bags. One of my friends, C., was a year older, taller, better looking, and more confident and outgoing, but we became close over the years. He was taking business classes in High School. I already knew I wanted to be a doctor. We lost touch after I started Medical School. The only time I see his face now is on the cover of The Wall Street Journal and when I occasionally watch TV during travel; he is the head of one of the world’s biggest multinational corporations. I sometimes wonder how come I couldn’t also have been a successful businessman, but then, I don’t even like to balance my checkbook, so why would I think I could have made it in the world of finance?

Closer to home, my High School classmate, J., also knew all along he wanted to be a doctor. He stayed on at the University Hospital where he went to Medical School, went into a subspecialty, got his Ph. D., and has been head of his department for many years. He has more influence in a vastly larger organization than I have, and his life seems more straightforward in the sense that he made his career right in his own back yard; he didn’t move halfway across the world and away from his family to find his life’s work. But sometimes when we talk, he speaks of my life as more exciting; considering the path not taken causes a twinge in each of us.

I just got an email again from my army buddy, L., who also started Medical School in Uppsala when I did. A few months into our first semester, his debut novel was published. A year and a half later, he dropped out of Medical School to write full time. He was just awarded one of the most prestigious literary prizes in Sweden. Before I even met L., I harbored secret dreams of writing a great novel. Forty years later, he is still putting them out, and my first one is still more of an idea than an actual draft. In his latest email, he expressed his admiration and approval of my Country Doctor lifestyle and confessed he was jealous about my having goats.

As I sit here near the end of my week off, I think of where I am in life right now. The minutes go so fast at work, and the evenings and weekends at home are so short; I don’t often have time to think as much as I have this week. While we were cooking this afternoon, Emma said, “This is the first time you’ve really just been home for a whole week in years.”

I know the psychological task for people my age is to make peace with who we are, and to gather up those dreams and desires we never seemed to have parted with willingly, as well as the wounds we never took time to heal; we must now give them their rightful, if only symbolic, attention in our lives in order to be whole persons.

The central idea in “Living Your Unlived Life” is that the “unlived” parts of our lives can be lived out in totally symbolic form – “Doing something by not doing it”. Symbols, unlike signs, have many interpretations and can even encompass seemingly opposite notions.

So, my only multinational business is being both a Swede and an American, practicing modern, yet old-fashioned primary care medicine in rural America among French-Canadian patients.

My only sphere of professional influence is my exam rooms and the community I serve. My life is here, and it is rich with nuances, contradictions and memories. I have few regrets, and even they make up part of the unique substance of my life.

My only literary calling, at least for now, is to keep adding to this five-year-old weblog about how it feels to do the work I do.

A Minute of My Time

Countless times during the course of my day, some person, entity or task vies for my time and attention.

“If I could just have a minute of your time” begins a request to also see the spouse of a scheduled patient, a sales pitch from a pharmaceutical “rep” or home oxygen vendor, a phone call from a visiting nurse, a message from a far away relative of an elderly patient in tomorrow’s schedule or a plea to complete the form Mr. Henderson forgot to bring with him for yesterday’s appointment. Unspoken, the same request lies behind every email, fax, memo, journal and invitation that finds its way to my office. A minute of my time doesn’t seem like too much to ask.

In years past I would consider such requests with a constant awareness of how much my time was worth to my employer. “Seven dollars a minute”, I would say, only half joking, when non-patients asked for a minute of my time. That is the “opportunity cost” for a minute of a family practitioner’s time in today’s American health care industry.

Lately, and probably not a minute too soon, I have started to very seriously ponder what each minute of my time is really worth. And I now understand better that time isn’t measured in dollars. Sometimes it isn’t even measured in minutes.

To the patients that entrust me with their care, a minute of my time could make the difference between a good visit and a less than satisfying one. It could make the difference between making the right diagnosis in the first visit or much later. To the far away relative, a minute could mean the difference between needless worry, calm reassurance, or planning a last trip to see their loved one before it is too late.

The emails, memos and invitations obviously pale in comparison to the things I originally went into medicine for, but I have tended to become distracted by the interruptions. And the dollars-per-minute way of thinking is really a very large distraction, too: Again and again I have found that when I don’t watch the clock I am more effective as a physician and more powerful as a healer. I diminish the value of my professional skill, experience and wisdom by thinking of my work in flat rate terms. A minute at a bus stop isn’t the same as a minute at the Symphony, is it?

And, thinking of my employer’s “opportunity cost” – what about my own? My organization will probably be there long after my time is up, so how much is a minute worth to me, since I have fewer of them? I know what the real answer is, I have just had trouble claiming it for myself: My time is invaluable, priceless.

When our horse started to colic today and I left the office early, four patients with routine appointments had to be rescheduled. I made sure they were safe before I drove home to help my wife handle the situation. In years past I would have struggled with guilt, but today I didn’t.

I have come to realize that your days are numbered in the pressure cooker that medicine today can be if you aren’t well rounded in your life. You can’t help others if you aren’t taking reasonable care of yourself. This doesn’t mean that one should be selfish, but it also means one shouldn’t be forever self-sacrificing.

Every time I watched the “safety on board” presentation before takeoff, I have startled at the idea of putting your own oxygen mask on before helping others with theirs. But it is good advice.

My goal is to live long and work until the end in my profession. I want to be the kindest, wisest physician I can be. I also want to be the kindest, wisest human being I can be.

It was about time I let go of my dollars-per-minute yardstick for the value of my time at work. It is also high time for me to think of all of my remaining minutes, 13 million if I live as long as my parents, as absolutely priceless.

The horse is doing fine. The goats are chewing their cud. The barn is warm and cozy under the starlit late winter sky. It is well below freezing and the crusted snow crunches under the cleats of my winter boots as I walk back across the yard to our little red farmhouse.

My stay-at-home vacation has started. I intend to spend it wisely.

Touching the Mezuzah

First published in 2012.

A mezuzah (Hebrew: מְזוּזָה‎ “doorpost”; plural: מְזוּזוֹת mezuzot) is a piece of parchment (often contained in a decorative case) inscribed with specified Hebrew verses from the Torah.

ט וּכְתַבְתָּם עַל-מְזֻזוֹת בֵּיתֶךָ, וּבִשְׁעָרֶיךָ. {ס} 9 And thou shalt write them upon the door-posts of thy house, and upon thy gates. {S}
                                        Deuteronomy 6:9

It’s almost 4:30 and I have three more patients to see before my Christmas mini-vacation can begin. Snow and sleet are beginning to fall outside. Our lab tech, who leaves between 3 and 3:30, just called from home to warn the rest of us that she had seen nine moose on Route 1, probably attracted by the road salt.

“Three encounters in thirty minutes”, I think to myself, “and neither of them completely straightforward”. I used to shudder when healthcare administrators called medical office visits “encounters” , but the more I have thought about it, the truer the word rings to me. Two people meet briefly and try their best to communicate in spite of sometimes very different viewpoints and agendas. I remember the phrase “Marriage Encounter” from my first visit to this country in the early 1970’s – an event where couples learn to see each other with new eyes and communicate more effectively.

I have three fellow human beings to interact with and offer some sort of healing to in three very brief visits. Three times I pause at the doorway before entering my exam room, the space temporarily occupied by someone who has come for my assessment or advice. Three times I summarize to myself what I know before clearing my mind and opening myself up to what I may not know or understand with my intellect alone. Three times I quietly invoke the source of my calling.

4:35 – In Room 1 sits Bill Boland, the fellow who always sasses me for my habit of knocking on the exam room door before I enter. He had been in with pneumonia and his x-ray came back suspicious for a tumor. The purpose of today’s follow-up visit is to make sure he is feeling better and to tell Bill he will need more testing. I raise my hand in an automatic door knocking gesture, but catch myself and instead touch the doorframe briefly and take a slow breath before entering the exam room, ready to deliver the disturbing news.

4: 50 – In Room 2 sits Wally Parker, here to talk about his blood sugars. His wife is in the hospital with a lower GI bleed, and her colonoscopy showed an ulcerated tumor that is almost certainly malignant. “Why is he here tonight instead of at Mary’s bedside?” I ask myself as my hand reaches for the doorframe. At the same time I try to clear my mind of my own clutter and my guesses why he has chosen to keep this appointment under these circumstances.

5 o’clock – The child in Room 3 is an 11-month-old with a fever. He belongs to the pediatric group in town, but probably the slick roads and the late hour are the reasons he is here. A new patient, and a sick child at that, requires me to be unhurried and receptive. I must be aware of how well we connect, so neither this child’s young mother nor I miss something important in our encounter. In this case, the child has an ear infection and the mother is a registered nurse with an older child at home who has recurrent ear infections.

At 5:15 I wish Autumn and the new receptionist a Merry Christmas before I leave through the back door.

Route 1 is covered with snow and the large flakes coming right at me make it impossible to see with high beams. I drive slowly with only my low beams, and don’t see a single moose.

Our house is all lit up for Christmas. In one of the sunroom windows shines the metal star-shaped lamp that hung in my bedroom window when I was a child. I remember coming home from school in the dark, looking up at my star on the third floor of our Swedish apartment building, even closer to the Arctic Circle than where I live now.

I can see my wife in the kitchen window, but she can’t see me in the darkness outside. I quickly stomp the snow off my boots on the wooden steps outside the door. My hand touches the doorframe for balance, physical and spiritual, and as a brief gesture of love and blessing:

I am home. It is Christmas.


I just realized none of the posts show on an iPad or a computer, but they do show on an iPhone. WordPress is working on this. In the meantime, please visit my Substack.

 

 

Osler said “Listen to your patient, he is telling you the diagnosis”. Duvefelt says “Listen to your patient, he is telling you what kind of doctor he needs you to be”.

 

BOOKS BY HANS DUVEFELT, MD

CONDITIONS, Chapter 1: An Old, New Diagnosis

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