A Country Doctor Writes:

“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?

I had seen Eldon Beauford almost every week for the last six months to monitor his congestive heart failure. Every time his weight went up, I temporarily increased his diuretics, and every time his heart rate was faster or slower than ideal, I adjusted the medications we used to rate-control his atrial fibrillation. Sometimes he would have episodes of shortness of breath with exertion that sounded more like atypical angina, in which case I adjusted his nitroglycerin regimen.

Eldon would move slowly as he began his day, weigh himself, then take a nitroglycerin before shaving and washing up. He followed a severely salt-restricted diet, and he took almost a dozen different pills.

His vital signs changed with every visit, and we patiently tinkered with the medications we had collected as tools to treat his ailing heart. He always seemed to want to be part of the decision-making process; I would explain my assessment, and he would generally agree to my plan, but not without double-checking my rationale.

He was no longer taking blood thinners for his atrial fibrillation after two hospitalizations for intestinal bleeding. The gastroenterologist and anesthesiologist who saw him in consultation both felt he was too frail to tolerate the anesthesia or endoscopy procedures to diagnose the bleeding. To continue with blood thinners in the face of ongoing intestinal blood loss would have been too risky, so we chose the less dramatic risk of leaving an almost 90-year-old man with atrial fibrillation without blood thinners, but with an increased risk of stroke.

Some visits I knew Eldon was getting better. He would tell me about places he had been and things he had done. Other visits, we seemed to be slipping backward in spite of all the medications we were using. He knew how precarious his situation was, and his expectations were small. He always seemed able to celebrate even the smallest victories.

A while ago, he took the bus downstate to spend a week with his daughter and son-in-law. He hadn’t seen them since Christmas, and spoke for weeks about his excitement to see them, their children and grandchildren.

Shortly after his return, his congestive heart failure flared up, and he suffered a fatal stroke. In the days that followed, I couldn’t get him out of my mind. He was such a gracious man, who lived life to the fullest within his severe limitations. I so wished I could have helped him more.

In Friday’s mail I got a card, with a postmark from near the southern border of the state.

The card read:

Thank you for the wonderful health care you provided for my father, Eldon Beauford. You always treated him with respect and compassion. You successfully managed his heart failure and enabled him to live the best quality of life that he possibly could. We were lucky to have you there for him. 

Sincerely,

Diana Daigle

I tucked the card away with others like it I keep in a drawer, mementos of patients and families whose lives I have been fortunate enough to touch over the years.

Lester Croppe never did come back for his follow-up two months ago. He did show up this week, however, with a big frown on his perpetually tanned, furrowed face.

I immediately got the sense that Lester was upset or unhappy, although I wasn’t sure why.

“It’s been a while”, I said tentatively. “Last time we talked I gave you an insulin pen to start getting those blood sugars down….”

“Before you go any further, I need to tell you something”, he interrupted.

“Yes?” I said.

“I didn’t like what you said last time about me having to go on the needle.”

“I can understand that”, I offered.

“So I got mad and decided to do something about it.”

I glanced at his vital signs. His weight was down almost twenty pounds and his blood pressure was better than I’d seen it before. I asked:

“What did you do?”

“I gave up drinking beer, cut back on snacking and made my servings smaller than before”, he thundered.

“Looks like it paid off!” I said. “What kind of blood sugars are you getting now?”

“Nothing over 220, and my fasting readings are perfect.” His stern face broke into a contented smile. “I wanted to prove that I didn’t need insulin”, he said, triumphantly.

“And prove it you did! Congratulations….”

“Thank you”, he said, offering his enormous, calloused right hand in a firm handshake. “At first, I got mad at you, but then I knew it was really my diabetes I was mad at.”

I have known for several months that things were coming to an end between Helen and myself, and that I would probably have to be the one to actually end our relationship.

Helen’s medical condition is quite ordinary, but her reaction to it is unusual. She is convinced that she has some dreadful, yet undiagnosed disease. Years before she even became my patient she had been thoroughly evaluated and all the tests had been normal. A few more confirmatory tests reassured me, but not Helen.

She spiraled into a deeper state of panic about her symptoms and she started to call Autumn several times every week with new concerns, demanding that we drop everything and reevaluate her. She has refused to go to the emergency room when her symptoms have sounded dramatic on the phone, and she has refused to see my colleagues at the clinic when I have been too booked up to see her right away.

I tried to apply my usual strategy for working with anxious, doubtful patients. I gave her weekly double-length appointments in order to show her I was taking her seriously and wanted to address all her concerns. By seeing her often I hoped to decrease her panic between visits, but this made no difference. She has also resisted the notion that her symptoms may be worse when she feels anxious about them. She vehemently refuses to see our behavioral health specialist.

Our last several visits have followed the same pattern: I would ask about her symptoms, which always remain the same, then I would ask about her medication, which she never takes as prescribed. She would then tell me she has spoken with an acquaintance – a nurse, pharmacist or fellow sufferer of a similar condition. Inevitably, this other person has nothing good to say about my diagnosis or proposed treatment strategy.

Every time Helen has brought up the concerns raised by her friends, I have responded by reviewing how I arrived at her diagnosis, what the literature recommends for treatment, how the medications are dosed and how one monitors the condition and the treatment. Every time I have done this, Helen seems okay with my treatment plan, but by the next time I see her, the process starts all over again.

During last month’s visit, I put her chart aside and said to her:

“You really don’t seem comfortable with how I am handling your medical care.”

“Well, it’s just that – I mean, how do we know we’re on the right track?”

I remembered Rhonda Weston, who for almost a year kept saying she wasn’t feeling right. Her physical exam and all her medical tests were normal, until suddenly she developed the slightest lymph node swelling, which turned out to be non-Hodgkin’s lymphoma. Within two years she was dead, despite the best of treatment by Boston and local oncology specialists.

I went over Helen’s symptoms, the testing we had done, the diagnosis and differential diagnosis and my treatment recommendation, based on the literature I had reviewed and shared with Helen. I explained to her that after going over her history and evaluating every symptom she has told me about, there was no sign at this time of anything more dangerous going on. I reminded her that I always wanted to know if any of her symptoms changed, so I could evaluate them in the context of what we already knew.

“No test is perfect, Helen, and that’s why I’m always checking in with you to make sure there aren’t new symptoms or new findings that we need to consider. I am doing my very best to keep an eye on your condition.”

She concluded:

“I do trust that you’re doing your best, it’s just that I’m scared.”

“You’re scared that there’s something I’m missing?”

She nodded.

“What’s your biggest fear, your deepest fear?”

“I don’t know; just that I have something bad.”

I told her I understood, but that it wasn’t in her best interest to stay under my care when she had so many doubts. I suggested she look for another doctor, who might make her more comfortable than I could.

“No, I want to stay with you”, was her answer.

A few weeks ago Helen told me about a fourth cousin in Philadelphia, with the same symptoms, who suddenly ended up in a coma and on life support at a university hospital.

I knew I wasn’t going to break through her fear. I gave Helen the names of three or four doctors within easy driving distance who are accepting new patients. I told her I was sorry I hadn’t been able to help her more and that we really couldn’t go on like this. I gave her formal notice to find another doctor within 60 days.

I didn’t expect to feel relieved after doing this, but I had not anticipated how sad I would feel.